Medigap - Medicare Supplement

  • Helps fill "gaps" in Original Medicare.
  • Helps pay some of the remaining health care costs and supplies not covered that Original Medicare:
    • Copayments
    • Coinsurance
    • Deductibles

Medicare will pay its share of the Medicare-approved amount for covered health care costs, then, your Medigap pays its share.

What you need to know about Medigap plans

  1. You must be enrolled in Medicare Part A & B.
  2. Medigap is NOT a Medicare Advantage. You CAN’T enroll in both.
  3. You pay a separate monthly premium for a Medigap plan.
  4. Guaranteed renewable is a feature of Medigap.
  5. Medigap policies do not include prescription drug coverage. You need to enroll into a separate Medicare Prescription Drug plan (Part D)
  6. It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage plan unless you are switching back to Original Medicare.
  7. Medigap policies do not cover long-term care, vision, or dental care, hearing aids, eyeglasses, or private-duty nursing.

Medicare Part D

  • Covers a wide range of prescription drugs
  • Has a list of covered drugs (formulary). 
  • Places drugs into “tiers” have a different cost per tier. For example, a drug in a lower tier will cost you less than a drug in a higher tier. 


    • Tier 1—lowest copay: most generic prescriptions
    • Tier 2—medium copay: preferred, brand-name
    • Tier 3—high copay: brand-name prescription drugs 
    • Tier 4—higher copay: non-preferred, brand-name
    • Tier 5—highest copay: Specialty tier highest cost prescription drugs 


Formulary Exception Rules

Medicare drug plans may have these coverage rules 

  • Opioid pain medication safety checks 
  • Prior Authorization 
  • Quantity limits 
  • Step therapy 
  • Part D vaccine coverage 
  • Drugs you get in hospital outpatient settings 


Formulary Exception requests are common among Medicare Beneficiaries. The request is best handled by your prescribing doctor.  

Your doctor feels you need a higher Tier drug instead of a similar lower Tier drug, your doctor may ask your plan for a Formulary Exception or Tier reduction to lower your co-pay may also come into play.